| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Case Report |
1 All authors: Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10019
Received July 2, 1999;
accepted after revision August 24, 1999.
Address correspondence to M. J. Gollub.
Introduction
 Top Introduction Case ReportDiscussionReferences |
|---|
This case is illustrative of the potential use of MR enteroclysis in treating small-bowel obstruction.
|
TopIntroductionCase ReportDiscussionReferences |
|---|
The patient originally presented with weight loss, abdominal pain, distention, and ascites on physical examination. Cytologic analysis of paracentesis fluid revealed mucinous adenocarcinoma. CT did not indicate a definite source of primary tumor but revealed prominence of the head of the pancreas. Chemotherapy was unsuccessful for presumed pancreatic carcinoma, and the patient underwent extensive surgery, including removal of his spleen, omentum, right colon, small bowel, and peritoneum. Histopathologic analysis revealed well-differentiated mucinous adenocarcinoma throughout the abdomen with an in-situ component in the appendix. After being lost to follow-up for 2 years, the patient returned for workup of possible bowel obstruction.
CT scans obtained from an outside institution and rereviewed by the authors were suboptimal because of a lack of thin axial slices and poor copy quality; however, the scans showed pseudomyxoma peritonei surrounding multiple loops of small bowel. There was moderate bowel distention and a suggestion of areas of narrowing without complete obstruction.
The referring surgeon, reluctant to reoperate on this patient who could have multiple points of small-bowel obstruction, contemplated a conventional small-bowel study to examine for small-bowel obstruction. This study was not performed because of the potential complications of administering barium to this patient who had altered bowel motility and slow transit; therefore, MR enteroclysis was performed for further examination (Fig. 1A,1B,1C,1D,1E).
|
|
|
|
|
The patient was given 10 mg of diazepam (Valium; Hoffman—La Roche, Nutley, NJ) and 20 mg of metoclopramide orally before the procedure. Orogastric intubation was performed under fluoroscopy using a 13-French catheter-guidewire device (Maglinte catheter; Lafayette Pharmaceuticals, Lafayette, IN). The tip was anchored just beyond the Treitz's ligament. The routine barium phase was eliminated. Instead, 30 ml of barium sulfate (50% w/v) (Entrobar-H; Lafayette Pharmaceuticals) was infused to ascertain placement of the catheter and to assess the degree of bowel obstruction. Subsequently, 1200 ml of 0.45% methylcellulose (Entrocel; Lafayette Pharmaceuticals) was infused using a hemodialysis pump (Minipump; Renal Systems, Minneapolis, MN) at 70-90 ml/min according to patient tolerance.
After removal of the tube, the patient was transferred to the MR imaging suite, received 0.9 mg glucagon IV, and underwent imaging with the torso phased array coil (Torso Array; Medrad, Indianola, PA) on a 1.5-T magnet (GE LX; General Electric Medical Systems, Milwaukee, WI). Multiplanar images were obtained using the single-shot fast spin-echo pulse sequence images (TE range, 93.9-97.3; field of view, 380 mm; slice thickness, 3-5 mm; gap, 1 mm; matrix, 256 x 256; signal averages, 0.5).
The images revealed peritoneal high-signal-intensity material (Fig. 1A) and scalloping of the liver surface (Fig. 1B), indicative of pseudomyxoma peritonei. Multiple points of narrowing and tortuosity of the bowel with prestenotic dilatations were noted (Figs. 1B,1C,1D,1E). The points of intestinal narrowing were considered to be a result of adhesions and compression from mucinous material. Because of the multiple points of small-bowel obstruction and bulky mucinous material surrounding the bowel, the surgeon opted not to reoperate on the patient and instead offered supportive care.
|
TopIntroductionCase ReportDiscussionReferences |
|---|
When these examinations do not address clinicians' concerns, enteroclysis may be used. Enteroclysis is an excellent examination for low-grade intermittent small-bowel obstruction, an entity in which CT may fail to detect a site of obstruction as a result of minimal caliber discrepancy. In this clinical scenario, enteroclysis has an accuracy of 85% because of the fluid challenge involved in the procedure [5].
The latest trend has been to combine enteroclysis with cross-sectional imaging to better depict associated mural and extramural abnormalities. The use of CT enteroclysis in small-bowel obstruction has been recently reported [7].
Several groups in Germany, using the rapid MR imaging technique usually used in MR cholangiopancreatography that has the known ability to "freeze" bowel, obviating any motion artifacts, have reported early experience with MR small-bowel imaging of Crohn's disease using enteroclysis for bowel distention [1,2,3,4].
With the knowledge of this preliminary data, we suggested MR enteroclysis to eliminate the barium phase of a conventional enteroclysis examination. Though a CT enteroclysis could have been performed, because of the additional radiation of CT and the superior soft-tissue contrast with MR enterocylsis, we chose the latter.
The fine detail of the images (especially the individual valvulae conniventes) (Fig. 1A), exceeds the detail of any other imaging technique for depiction of small-bowel anatomy. This is a result of a combination of snapshot image acquisition and the inherent soft-tissue contrast afforded by MR imaging. With enteroclysis, we obtained a more accurate assessment of the sites and cause of bowel obstruction than with the outside CT scan because of the fluid challenge afforded by the enteroclysis, the increased anatomic detail and soft-tissue contrast afforded by MR imaging, and the single-shot fast spin-echo sequence. Admittedly, the presence of mucin increased the conspicuity of the wall of the small bowel. Nonetheless, as previously described [8], use of a shorter-than-usual TE for this sequence allowed better visualization of the intestines and surrounding soft tissues.
We completed the enteroclysis 30 min before MR imaging and transported the patient to the MR imaging suite; however, the patient's intestines remained well distended because of the intestinal obstruction. In a patient with no obstruction, this sequence of events might have delayed imaging at the time of optimal bowel distention; thus, contrast infusion might need to be performed during MR imaging or in the MR imaging suite immediately before scanning.
MR enterocylsis may also be berformed with both negative and positive oral MR contrast enhancement, including iron-based [4] and gadolinium-based agents [2,3], respectively.
Examination of the small bowel with MR enteroclysis presents a new and exciting method with great potential in the investigation of sources of blood loss, malabsorption, obstruction, inflammation, and neoplasm. The eventual place of MR enterocylsis in the diagnostic workup of small-bowel obstruction remains to be seen.
In conclusion, MR enteroclysis in a patient with pseudomyxoma peritonei produced highly detailed images of the small bowel that allowed diagnosis of small-bowel obstruction at multiple levels. This allowed our surgeons to assess the small-bowel obstruction before potential surgery with high-quality images while avoiding the use of additional barium and radiation.
|
TopIntroductionCase ReportDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  D. D. T. Maglinte, E. S. Siegelman, and F. M. Kelvin MR Enteroclysis: The Future of Small-Bowel Imaging? Radiology, June 1, 2000; 215(3): 639 - 641. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
